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Priceless Behavior

Part of the nation's health problem may have more to do with education than medical care.


Name

Penelope Lemov

Penelope Lemov is a GOVERNING correspondent. She was GOVERNING's health columnist and was senior editor for several award-winning features.

If you build it, they may not come. That's one of the frustrations for health policy makers. Even when the neediest citizens gain access to health insurance, that may not be enough to improve their odds of living a healthy life.

Here's a case in point. Florida's Medicaid program is offering beneficiaries financial rewards for doing certain healthy things. The tasks in question aren't terribly demanding -- no one has to lose 25 pounds or run five miles a day. Rather, each participant can earn up to $125 a year in credits for such seemingly easy-to-do health activities as keeping a doctor's appointment or getting a flu shot. And the credits are almost as good as cash. They can be used to buy shampoo, vitamins and other health-related items at participating pharmacies.

And yet, the program "has been expensive to launch and slow to catch on, raising questions about its effectiveness and efficiency." That's the assessment of a research report from Georgetown University's Health Policy Institute, which notes that the first-year administrative costs of the program were $1.1 million. That same year, beneficiaries redeemed only $300,000 in credits. The numbers have a whole lot of Floridians -- and officials in other states that are following the pilot -- feeling dismayed about the power of incentives to get people to do the right thing when it comes to their health. "There's a question," says Joan Alker, a senior researcher with the institute, "whether this approach will actually work to change people's behavior."

Alker's words came to mind while I was digesting some of the equations and yield curves presented by health economists at a symposium held by the American Enterprise Institute. The event had the challenging title, "Beyond More Health Insurance Coverage, toward Better Health Outcomes." AEI had assembled a panel of renowned academics to break out from the usual debates about how to reduce the number of uninsured. Instead, they were asked to talk about how health policy makers could produce more bang for the bucks spent on less affluent patients.

One point became clear from the outset: Education plays a key role in one's ability to make use of health care. Genes and bad luck aside, the higher up the educational ladder, the healthier and longer life a person is likely to live. High school dropouts, the statistics show, are not likely to live to a ripe old age. Just getting a high school degree decreases the probability of being in poor health by 35 percent; a bachelor's degree decreases the chances by 55 percent. "Education," explained Robert Kaestner of the University of Illinois at Chicago, "makes it easier for people to obtain and process information about the causes and consequences of health."

This could partly explain why some participants in Florida's rewards program did not capitalize on the program. Another explanation may come from James Heckman, another AEI speaker and a Nobel Prize winner from the University of Chicago. Heckman talked about the importance of early-childhood education in helping people to form skills such as self-regulation, motivation, time preference and far-sightedness, all of which come into play when a person seeks out health care. According to Heckman, those with "greater self control and conscientiousness follow medical instructions and take care of themselves in a variety of ways." He noted that the gaps in these cognitive and non-cognitive abilities -- between individuals and across socioeconomic groups -- are substantial and open up at early ages. The same is true for deficits in health status. These deficiencies, he noted, "are not all about access to health care services. Family and environmental conditions in the early years are predictive of adult outcomes, including health."

Heckman's bottom line: There is a high return for investments in at-risk children, particularly when those interventions come early in a child's life. Remediation later in life is more expensive and less effective. Children without social-emotional abilities such as motivation and perseverance -- along with cognitive skills -- are much more likely to drop out of school and have poor health later in life.

If you buy into the logic presented by the AEI panelists, the take-away for state Medicaid programs is this: It pays to put resources into programs that provide consistent and good care from the prenatal period on. Such "interventions" could -- in some future day -- preclude the need to hand out incentives for keeping a doctor's appointment.


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